PIP COVERAGE FOR EMERGENCY MEDICAL CONDITIONS: IS THE LIMIT $10,000 OR $2,500?

All Florida auto insurance policies must include Personal Injury Protection
coverage. This is commonly referred to as “PIP” coverage.
What is Personal Injury Protection and what are the coverage limits. The
answers to these questions are primarily found in Florida Statute 627.736,
but are not always simple to decipher.

WHAT IS PERSONAL INJURY PROTECTION AND WHAT DOES IT PAY?

Florida Statute 627.736 requires your auto insurance policy to provide
coverage up to $10,000 for medical benefits and disability benefits, and
another $5,000 for death benefits. For medical benefits the coverage is
to pay 80% of non-excluded reasonable expenses for medically necessary
medical, surgical, X-ray, dental, and rehabilitative services, including
prosthetic devices and medically necessary ambulance, hospital, and nursing
services. For disability benefits, the coverage is to pay 60% of any loss
of gross income and loss of earning capacity per individual from inability
to work caused by the auto accident injury, plus all expenses reasonably
incurred in having to pay someone else to such things as housework or
yard work that the injured person would normally have done themselves.

WHEN DOES PIP NOT HAVE TO PAY THE FULL $10,000 IN MEDICAL/DISABILITY BENEFITS?

To receive the maximum amount of $10,000 of medical/disability benefits
under the PIP policy, there must be a determination an emergency medical
condition resulted from the accident. Otherwise, the PIP statute limits
the benefits to $2,500. Most auto accidents will either have clear proof
of an emergency medical condition, resulting in coverage up to $10,000
or will have clear evidence there is no emergency medical condition, resulting
in a cap of coverage at $2,500. But, what happens when there is no evidence
either way? In Medical Center of the Palm Beaches vs. USAA Casualty Insurance
Co. (No. 4D14-3580), the Fourth District Court of Appeal recently looked
at what should happen when there has been no determination by medical
doctors in the initial records of an “emergency medical condition”
resulting from the auto accident.

The injured driver in this case developed pain to her right shoulder and
cervical region after a car accident. She went to a treating doctor to
discuss this problem and was simply referred to a physical therapy practice
for conservative treatment without there being an actual determination
of the nature and extent of her injury. She went to physical therapy,
and the therapy facility then submitted bills for this treatment to the
PIP insurance carrier for the patient. The insurance company refused to
pay, explaining that it had no evidence of an emergency medical condition
and the injured woman had already met her $2,500 limit. The physical therapist
office sued the insurance company for breach of contract for not paying
the bills and also sent a note from the injured person’s treating
physician, who had subsequently and retroactively diagnosed her with an
emergency medical condition. The trial court ruled in the insurance company’s
favor on summary judgment, agreeing with the insurer that the limit is
$2,500 in the absence of an determination of an emergency medical condition
from the outset. The physical therapist office appealed and argued that
the statute only limits the payment to $2,500 when a statutorily authorized
provider determines there is no emergency medical condition. In this case,
the initial notes of the treating doctor were apparently silent on the
issue and the facility’s position was that the default should be
payment up to $10,000 in the absence of a negation.

The appellate court, with an interesting twist of logic, disagreed with
the physical therapy office and denied payment beyond $2,500. In doing
so, it looked at the wording of the statute which first limits the PIP
benefit to $10,000 for an emergency medical condition. The statute then
limits the benefit to $2,500 when there’s been affirmative proof
there was no emergency medical condition. The statute does not address
the specific situation of no determination at all. Rather than reaching
the decision that the insurance company could only rely on the $2,500
cap when affirmative proof exists that no emergency medical condition
resulted from the accident, the court decided to let the insurance company
off the hook by allowing the $2,500 cap when the records of treatment
are silent on whether an emergent medical condition exists. Was this truly
the legislative intent of the statute? Or, should the court have looked
at the totality of the evidence available to determine whether coverage
should be for $2,500 vs. $10,000?

The 4th DCA does not issue controlling decisions for North Florida, so
this logic does not have to apply to cases in our area. If you’ve
been injured in an auto accident, you rely on prompt payment of benefits
by your insurance company. Questions about the coverage that’s available
to you under your policy can be answered by the personal injury attorneys
at Syfrett, Dykes & Furr. Contact our office today at (850) 795-4979
for a free and confidential consultation.

The information on this website is for general information purposes only.
Nothing on this site should be taken as legal advice for any individual
case or situation. This information is not intended to create, and receipt
or viewing does not constitute, an attorney-client relationship.

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